30 July 2010

She was, my patient conceded, "a bit overweight." In medical terminology, she was morbidly obese. She weighed about 280 pounds, and her BMI was somewhere over 50, seeing as she stood only five foot two. In more vivid verbiage, she might have been described as resembling nothing so much as a bowling ball, a round body with spindly legs and arms jutting out at improbable angles.

Her complaint was "headache" and her temperature was 102.8 degrees Fahrenheit. She was on multiple immunosuppressants, including steroids, for a mixed connective-tissue disorder. There was no apparent explanation for her fever -- no urinary tract infection, no cough or runny nose. As I gently flexed her neck forward, she winced.

And I winced.

Because there was just no option -- she needed a spinal tap to assess for meningitis. And with a body type like hers, the likelihood was that it would be a flog. I could see where this was going to end up -- a half hour of torturing this nice lady trying to get the tap myself; a call to interventional radiology and the obligate half-hour delay in the call-back; enduring the open scorn (best case) or scathing abuse (worst case) of the radiologist who was called in the middle of the night to do the procedure under x-ray guidance. There was seven hours left to go in my shift, I reflected, and I would be lucky if I could get the disposition accomplished before then.

So, first off, I got set up to give it the obligate college try. Lie her on her right side and set up the table as usual, as if this is anything other than going through the motions. I set up the test tubes, neatly in a row, as if there is a chance they will soon be filled with glistening CSF. I go through my usual pre-procedure patter, trying to put her at ease and trying to get myself to believe that this is just like any other tap I will do this week.

Sitting on my little stool, face to face with the small of her back, I could not find a single anatomic landmark to guide me. The spinous processes were buried under a thick layer of fat and not at all palpable. The iliac crest at the top of the hip-bone was similarly obscured. For that matter, I couldn't even positively identify the midline! The nurse and the patient's husband watched me, their expressions full of a simple confidence that I would quickly put this to rest. How little they know, I thought. I was careful to give her a healthy dose of numbing medicine and premedicated her for the procedure with dilaudid, figuring I was about to be causing her some pain. I made my best estimate of the locations and angles I would try, placed the needle against her clean skin and closed my eyes before sliding the needle in by feel alone. I waited for the sudden, hard resistance that would indicate I had just rammed the needle into bone. But it didn't come. Bemused, I pulled the stylet back and peered into the hub of the needle. Crystal clear fluid briskly welled up and began to drip out.

My jaw was hanging open behind my surgical mask, but my eyes and voice hid my astonishment as I said "We're in," in my most professional tone and began to collect the fluid. The nurse cooed, "There, that wasn't so bad, was it?" And the patient replied, "I didn't feel a thing. Is it always that easy?"

Easy? Yeah, that's the word for it: easy. Well, as far as they know...

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The icing on the cake came an hour later:WBC: 0RBC: 0Originally Posted 16 July 2007

If you're not one to always measure opening/closing pressures, I find that doing the taps with the patient sitting up can help identify midline and oft-times other landmarks. Once you are in, you can reposition the patient to side-lying for pressures if your neurologists always demand it.

Nice shot and great outcome. Although I have been lucky (or good?) many times in the past in similar situations it has been an unsuccessful affair of harpooning. 300+ pounds in the middle of the night and you get vanco, rocephin, decadron, and admitted until IR and ID figure out what to do.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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